Crying Baby with Acute Distress
Try out this paediatric case and test your clinical knowledge. The answers are at the bottom.
Questions
A 6-month-old boy presents to A&E resus with his mother. He appears distressed and is crying weakly. His mother mentions that he was feeling well yesterday and that he seems to have gotten unwell very quickly today.
PMHx:
G1P1
36+2 weeks delivery – elective C section with epidural (Nil complications)
Nil complications during pregnancy
Routine immunization up to date
Allergies:
NKDA
Observations:
SpO2: 79% (FiO2 100%)
Temperature: 40.4
BP: 50/37
HR: 201
RR: 68
Examination:
A: Weak cry. Significant drooling and stridor.
B: SpO2 79% on FiO2 100%. Reduced air entry bilaterally
C: CRT 6s, HS faint. ECG: no changes
D: Paediatric GCS 12 – responding to voice. PEARL. BM 5.1
E: Abdomen: SNT. No focal neurological signs detected.
Q1: What does G1P1 stand for in his past medical history?
The child is quickly intubated and an IO device inserted. An X-ray is also performed:
Q2: Comment on the X-ray – what is the diagnosis?
Q3: What further management should be initiated?
Q4: What is the most likely causative organism and how can this condition be prevented?
Answers
Reveal the Answers
G and P stand for gravidity and parity respectively. Gravidity is defined as the number of pregnancies, while parity refers to the number of foetuses the woman has carried until 24 weeks or more (regardless of whether the foetus is alive or stillborn). In this case this child was the mother’s first pregnancy and he was born after 24 weeks. Occasionally there may be third term ‘abortus’ which refers to the number of foetuses that are lost due to any reason and is often expressed as G1P1+0A.
This is a lateral neck X-ray showing significant laryngeal oedema and thickening of the aryepiglottic folds. This is often known as the “thumbprint” sign, and is a hallmark of epiglottitis.
The primary aim in epiglottis is to secure the airway, which has been performed by the anesthetist. Following from this, this child is likely in severe sepsis and as such it would be prudent to initiate the sepsis six:
Resus Fluid bolus: 20ml/kg
Blood cultures
IV antibiotics – empirical IV therapy with a cephalosporin is appropriate e.g. cefalexin
ABG – for PaO2 and lactate readings
Catheter
A further management option would be to insert a flexible nasal endoscope and to suction some of the bacterial gunk in the epiglottis under ENT.
The causative organism is usually Haemophilus influenzae type B (HiB), a gram-negative coccobacillus. Children are routinely immunized against this bacteria and condition with booster doses at 8 weeks, 12 weeks, 16 weeks and 1 year. In this child’s case, he was not old enough to complete the routine vaccination schedule.
Sources
Image 1: Case courtesy of Dr Maxime St-Amant, Radiopaedia.org. From the case rID: 26840
Dr Amol Joshi
University of Cambridge
University of Cambridge
About The Author
This clinical case is written by Dr Amol Joshi who has an interest in writing medical puzzles.
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